Thank You for the Invitation Japan Society of Plastic Reconstructive Surgery Dr. Professor Nozaki

Transcription

1 Thank You for the Invitation Japan Society of Plastic Reconstructive Surgery Dr. Professor Nozaki

2 Choices In Implant Placement Over Versus Under, Trends and Techniques Brian M. Kinney, MD, FACS, MSME Past President, Plastic Surgery Educational Foundation Clinical Asst. Professor of Plastic Surgery USC Division of Plastic Surgery Los Angeles, CA, USA

3 Disclosure Serve on Implant Advisory Council for Mentor Corporation Serve as a consultant for Dermik Division of Sanofi/Aventis Serve on the Board of Bioelectronics Corporation Brian M. Kinney, MD, FACS, MSME 3

4 Patients Can Decide Their Future Every women will look better than her friends at one point in her life She chooses when that is, age 20 or age 40 Age 20 Size B versus size D Implanted or not Age 40 Size B looks more nearly the same Size D dramatically different Ptosis Loss of conical shape Striae Brian M. Kinney, MD, FACS, MSME 4

5 Basic Principles to Minimize Early Complications Precise diagnosis of anatomy Understand the integrated geometry Major (integrated, 3D, intrinsic) variables Shape Asymmetry Geometry/position of breast mound on chest wall Size Skin envelope to gland volume ratio Firmness and distribution of parenchyma Nipple areola contour Brian M. Kinney, MD, FACS, MSME 5

6 Basic Principles to Minimize Early Complications Precise diagnosis of anatomy Understand the integrated geometry Minor (linear, 2D, extrinsic) variables Width, height Sternal notch to nipple Ptosis Cup Tissue laxity Thickness (depth) Areola diameter Brian M. Kinney, MD, FACS, MSME 6

7 Implant Location, Texture And Shape General Trends Over the muscle, smooth, silicone Capsular contracture Under the muscle, smooth, silicone Improve capsular contracture Over the muscle, textured, silicone Improve capsular contracture Fewer ruptures, thicker shell Brian M. Kinney, MD, FACS, MSME 7

8 Implant Location, Texture And Shape Under the muscle, textured, silicone Improved mammography Silverstein mammography study Over the muscle, textured, saline Improved mammography FDA ban Brian M. Kinney, MD, FACS, MSME 8

9 Implant Location, Texture And Shape Over the muscle, textured, saline Wrinkling Implant show Trend towards larger implants The South Florida or Texas look Do you want to Supersize your order (McDonald s marketing)? Dissatisfaction with look and/or feel 9

10 Implant Location, Texture And Shape Over or under the muscle, tear drop, saline More natural emphasis March 2000 FDA prohibits use of word anatomic Hamas studies Decreased use of tear drop Brian M. Kinney, MD, FACS, MSME 10

11 Implant Location, Texture And Shape >? Silicone or saline Over or under Smooth or textured Tear drop or round Cohesive Titanium? Hydrogel Customization? Brian M. Kinney, MD, FACS, MSME 11

12 Doctor Oriented Thinking My friend (or the other surgeon) says they always should be over/under the muscle My friend (or the other surgeon) says they always should be textured/smooth My friend (or the other surgeon) says they always should be anatomic/round Brian M. Kinney, MD, FACS, MSME 12

13 Doctor Oriented Thinking I had a complication before This time they should be over/under the muscle This time they should be textured/smooth This time they should be anatomic/round Brian M. Kinney, MD, FACS, MSME 13

14 Patient Oriented Thinking We should be patient oriented, not procedure oriented! We should be outcome oriented, not product oriented! Years ago we did one size fits all rhinoplasty Do we want to do the same for breast augmentation? Brian M. Kinney, MD, FACS, MSME 14

15 Patient Oriented Thinking Some patients are not particular No prior experience Many prefer a specific method A friend had a certain procedure A friend had a complication Previous consultations, news media, etc Anatomic considerations Brian M. Kinney, MD, FACS, MSME 15

16 Choosing Size and Implant Location The larger the implant the more unnatural the look The more the mound is made of implant, the more it looks like an implant! The larger the breast the sooner the ptosis Whether natural or augmented Brian M. Kinney, MD, FACS, MSME 16

17 Breast Mound - Muscle Under (Half Under) Only half under the muscle Muscular, not ptosis classification Type I, breast superior to pectoralis Type II, inferior breast below pectoralis Type III, nipple at inferior pectoralis Type IV, upper pole below inferior pectoralis 17

18 Breast Mound - Muscle/Skeletal Positioning Not only IMF-nipple/ptosis relationship Also, chest wall-breast mound-intercostal space relationship IMF is a fixed point for reference for a given patient, but.. IMF varies in location to costal margins, patient to patient Trunk vertical height ratio (chest to abdomen) varies 18

19 Breast Mound - Muscle/Skeletal Positioning Sternal width (percentage width of chest) varies IMF position (percentage location from costal margin to clavicle) varies 19

20 Evolution Of Under The Muscle Scenario I (implant stays high) Check back 5-10 years later Implant originally held under the muscle Breast ptosis..but Implant firmly held under muscle The alive, under the muscle, wonder bra keeps the implant in place Elongated breast Not a double bubble Taffy breast Not the natural location Most rippling is lateral to pectoralis! Therefore the subpectoral placement doesn t always help What percentage of rippling is upper, medial? Implant location doesn t matter as much as it seems 20

21 Evolution Of Under The Muscle Scenario II (implant goes low) Check back 5-10 years later Not under the muscle anymore Breast ptosis but Implant migration downward with gravity No longer submuscular Isaac Newton s apple Inferiorly displaced breast Not a double bubble, IMF intact The rock in a sock Not the natural location either Rippling is generalized! Position doesn t matter as much as it seems 21

22 Breast Mound Skeletal Platform 1 st 3 rd Intercostal spaces Narrow Implant superior margin close to clavicle Minimal chest wall showing Breast mound fullness on top Smaller implant to avoid upper pole fullness Wide Implant superior margin far from clavicle Maximum chest wall showing Breast mound concavity on top Larger implant for upper pole fullness 22

23 Breast Mound Implant Size And Aesthetics 150cc breast + >300cc implant = 1/3 breast, 2/3 implant = unnatural look 150cc breast cc implant = ½ breast, ½ implant = natural look Same proportions go for large breast It s really simple!! The more % the breast is occupied by an implant The more the breast will look like an implant Brian M. Kinney, MD, FACS, MSME 23

24 Breast Mound Size And Aesthetics Larger breasts distort, droop more Implanted or not Higher chance of future surgery At some point, guaranteed if desire to maintain youthful breast Each patient will look better than her friends at one point in her life If full Look good in her 20 s Look ptotic in her 40 s If small Look small in her 20 s Look nice in her 40 s Increase in % body/breast fat and size Minimal ptosis Brian M. Kinney, MD, FACS, MSME 24

25 Breast Mound Aesthetics This is a sliding scale! The greater % is implant, the more unnatural Implant/breast < 0.5 = natural? Before the era of obesity and implants Only about 10% of women were D cup Brian M. Kinney, MD, FACS, MSME 25

26 Breast Anatomy Orientation Over/under is off the main point Primary reference point for augmentation It is not the IMF!! It is the nipple Remember the pectoralis implant position The most projecting point of the mound must be at the nipple The implant must be centered under the nipple! Brian M. Kinney, MD, FACS, MSME 26

27 Over Under The Muscle Poor nomenclature Under the muscle = ½ under the muscle Most problems are NOT superior or medial Wrinkling 2 cm rule Large implants, large problems Wrinkling Atresia Distortion Decreased sensation Inferior migration Brian M. Kinney, MD, FACS, MSME 27

28 Over Under The Muscle When silicone gel are available 80-90% choose gel in other countries I don t have precise data for this Based on numerous personal communications Easier to choose over the muscle when fewer potential complications, such as Patient prefers a smaller size Wrinkling Improved shape Palpability Superior handling characteristics Looks more like a breast God made the breast on top of the muscle.but sometimes it is better under Brian M. Kinney, MD, FACS, MSME 28

29 Over Under The Muscle Major relationships Muscle release Medial cleavage Implant diameter Tissue cover Brian M. Kinney, MD, FACS, MSME 29

30 Over Under The Muscle Incisions locations vary Axillary Breast scarring Nipple sensation? Inframmamary Traditional Periareolar Less pulling, stretching Brian M. Kinney, MD, FACS, MSME 30

31 Implant Location - Subglandular Subglandular (over the muscle) >2 cm of breast tissue or fat anteriorly Small implant/breast ratio (<.5?) Doesn t want to be too big Previous capsular contracture under the muscle Ptosis, but only wants a small scar No Benelli? Wants to be natural Prefers motion Is a I want it to look good woman Brian M. Kinney, MD, FACS, MSME 31

32 Implant Location - Subglandular Over the muscle Afraid of looking too big on top Weightlifter (golfer, tennis player, etc.) Implant distorts the muscle More sight oriented patient My friend had it that way I heard it was better that way Dislikes the pushup bra look Wants medial cleavage Doesn t like the satellite dish pointing at the sky look when supine Using silicone implant Brian M. Kinney, MD, FACS, MSME 32

33 Implant Location - Submuscular Under the muscle Thin pectoralis, not athletic Small pectoralis, athletic, small implant Implant/breast <0.5? Is a I want it to feel good woman My friend had it that way I heard it was better that way Thin medially, afraid of wrinkles Brian M. Kinney, MD, FACS, MSME 33

34 Implant Location - Submuscular Under the muscle Push up bra without the bra More fullness on top Wants firmer feel, less motion The safety in numbers approach Transaxillary +/- endoscope <2cm of breast tissue overall Minimal cover upper/medial quadrants Brian M. Kinney, MD, FACS, MSME 34

35 Implant Location - Submuscular Under the muscle Removal of saline in secondary procedure is difficult Water doesn t flow like silicone Exchange implant instead of reuse Puncture implant to drain and remove 35

36 Under The Muscle Over The Muscle More bruising More swelling More pain More bleeding? Slow return to ADL s Less natural look Non- anatomic Less bruising Less swelling Less pain Less bleeding? Fast return to ADL s More natural look Anatomic Brian M. Kinney, MD, FACS, MSME 36

37 Under The Muscle Over The Muscle To Stimulate Discussion Feels more natural Fuller on top Less wrinkling Better in thin patient Alive, under the skin Wonder Bra Better in mild ptosis Worse in severe ptosis Feels like implant Less on top More wrinkling Better in muscular pt No Wonder Bra effect Poorer in mild ptosis Better in severe ptosis Brian M. Kinney, MD, FACS, MSME 37

38 Smooth Under Textured Under To Stimulate Discussion Moves naturally Lateral fallout when supine Early massage Stays put Central fullness when supine No massage? Brian M. Kinney, MD, FACS, MSME 38

39 Chest Wall Configuration Over The Muscle Wide, thin, high pectoralis Minimal implant coverage required Lower pectoral border/imf far above costal margin Implant will look high if 100% under the muscle Look at nipple to costal margin relationship If far, plenty of room for implant above the muscle Implant will be properly positioned Brian M. Kinney, MD, FACS, MSME 39

40 Chest Wall Configuration Under The Muscle Narrow, thick, low pectoralis Maximum implant coverage required Lower pectoral border, IMF near the costal margin Implant will fall low if over the muscle Loose areolar tissue Implant will not be too high if under the muscle Look at nipple costal margin relationship If close no room for implant except under the muscle Brian M. Kinney, MD, FACS, MSME 40

41 Subglandular 270cc Round Textured Wants a full C Axillary incision Preop 18 months postop Brian M. Kinney, MD, FACS, MSME 41

42 Subglandular 330 cc Textured Round Subglandular 400 cc Textured Teardrop Worried about wrinkles Four years postop, 2 pregnancies, breast feeding x 2 Grade 1 capsule, without ptosis 18 mos postop #1 5 yrs postop #1, preop #2 Brian M. Kinney, MD, FACS, MSME 42

43 Subglandular 330 cc Textured Round Subglandular 400 cc Textured Teardrop Wants to have back what she lost from breast feeding 18 mos postop #1 6 yrs postop #1, 6 mos #2 Brian M. Kinney, MD, FACS, MSME 43

44 Subglandular 330 cc Textured Round Subglandular 400 cc Textured Teardrop Wants a full C again Worried about wrinkles Wants to have back what she lost from breast feeding 5 yrs postop #1 6 yrs postop #1, 6 mos #2 Brian M. Kinney, MD, FACS, MSME 44

45 Subglandular 330 cc Textured Round Subglandular 400 cc Textured Teardrop Wants a full C again Worried about wrinkles 5 yrs postop #1 6 yrs postop #1, 6 mos #2 Brian M. Kinney, MD, FACS, MSME 45

46 Submuscular 300cc Round Wants submuscular Afraid of being big Implant equidistant above and below pectoral line Brian M. Kinney, MD, FACS, MSME 46

47 Submuscular 300cc Round Wants submuscular Afraid of being big Implant equidistant above and below pectoral line Brian M. Kinney, MD, FACS, MSME 47

48 Submuscular 330cc Textured Anatomic Willing to be over or under Doesn t want to be full on top, no Wonder Bra Brian M. Kinney, MD, FACS, MSME 48

49 Submuscular 330cc Textured Anatomic Willing to be over or under Doesn t want to be full on top, no Wonder Bra Brian M. Kinney, MD, FACS, MSME 49

50 Submuscular 330 cc Round Textured Relaxed Contracted Doesn t like elongated breast or muscle contraction 9 years postop Dissection superior to inferior areolar horizontal line Dissection superior to 4 o clock line Brian M. Kinney, MD, FACS, MSME 50

51 Submuscular 330 cc Round Textured Relaxed Contracted Doesn t like elongated breast Muscle contraction defect 9 years postop Give me as big as they make them 5 11, 140 pounds Brian M. Kinney, MD, FACS, MSME 51

52 Submuscular 330 cc Round Textured Bending Over, Muscles Relaxed Brian M. Kinney, MD, FACS, MSME 52

53 Submuscular 300cc Smooth Natural history of under the muscle Elongated breast, taffy breast R Ptosis, rock in a sock L 17 yrs postop Brian M. Kinney, MD, FACS, MSME 53

54 Submuscular 300cc Smooth Elongated breast R Descended implant L Brian M. Kinney, MD, FACS, MSME 54

55 Subglandular 330cc L Textured L breast cancer reconstruction x 2 with implants L dropout Submuscular wouldn t matter Age 35 Brian M. Kinney, MD, FACS, MSME 55

56 Subglandular 330cc L Textured L breast cancer reconstruction x 2 with implants L dropout Submuscular wouldn t matter Age 35 Brian M. Kinney, MD, FACS, MSME 56

57 Subglandular 330cc L Textured L breast cancer reconstruction x 2 L dropout corrected Submuscular wouldn t matter Age 35 Brian M. Kinney, MD, FACS, MSME 57

58 Subglandular Textured 270cc Submuscular Smooth 300cc Look OK Doesn t like the feel when she runs 34A and wants to be a small C Brian M. Kinney, MD, FACS, MSME 58

59 Subglandular Textured 270cc Submuscular Smooth 300cc Look OK Doesn t like the feel when she runs 34A and wants to be a small C Preop concave, postop linear Brian M. Kinney, MD, FACS, MSME 59

60 Subglandular Textured 270cc Submuscular Smooth 300cc Move from over to under Likes the way they feel Support while running Brian M. Kinney, MD, FACS, MSME 60

61 Subglandular Textured 270cc Submuscular Smooth 300cc Move from over to under Push up bra look Likes the way they feel SubG linear, SubM convex Brian M. Kinney, MD, FACS, MSME 61

62 Thank You Brian M. Kinney, MD, FACS, MSME 62